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Wednesday, June 1, 2011

The RDI program and its effectiveness for our children

A brief introduction to Relationship Development Intervention®

Relationship Development Intervention (RDI®) is based upon research in developmental psychology and the developmental psychopathology of autism spectrum disorders. The specific focus of RDI is to create a ‘guided participation’ relationship with caregivers, through which children develop competence in handling gradually more complex environments. The programme involves supporting families and caregivers/school staff in their roles as participant guides, creating daily opportunities for adaptive and thoughtful responding in the face of novel and increasingly unpredictable settings and unexpected change. Through participation in caregiver-guided continually more complex cycles of regulation, challenge and new regulation, the aim is for individuals on the autism spectrum to learn not only to tolerate, but also to enjoy changes and transitions.

The RDI Program focuses on developing:· an appropriate mix of verbal and non-verbal communication· abilities to engage with others· declarative, self-regulatory and self-narrative language · episodic memory· reciprocal, genuinely fulfilling relationships; · pleasure in living in dynamic environments where change is enriching

Relationship Development Intervention® involves rigorous and extensive training procedures and monitoring of competence, ensuring quality of care as well as treatment adherence. RDI is implemented through intensive parent education, customised and balanced planning, modelling and role-playing, and involving parents in a support network, regular videotape review of parent-child performance, and school staff training and consultation.

There are four sources of evidence that together provide grounds for believing that RDI is effective in ameliorating autism-specific behavior, especially in relation to the children’s limitations in social engagement and flexibility in thinking and action:

1. Gutstein, Burgess, & Montfort (2007) report on the 3-year follow-up of 16 children who met 'gold standard' criteria (ADOS/ADIR) for autism, Asperger’s syndrome or autism spectrum disorder prior to treatment with RDI. Marked clinical improvements after RDI were reported; for example, whereas prior to treatment 10 had ADOS scores corresponding with the diagnosis of autism, none did so at follow-up, at which point five were classified as ‘autism spectrum’ and five as ‘non-autism’. There were especially marked improvements in the children’s capacity to share experiences with others. Semi-structured interviews with parents revealed that the children’s flexibility had significantly improved. Moreover, there had been positive changes in the children’s educational placements. In this study there was not a treatment-as-usual control group (a previous pilot study had included such a control group who did not show the gains of the RDI-treated group). Having said this, the magnitude and breadth of this response to RDI renders it very unlikely that the effects were non-specific.

2. Aldred, Green, & Adams (2004) report a randomized control trial of an intervention for autism that has close affinity with RDI in its attempt to foster developmentally effective parental input through a focus upon the children’s social deficits. The approach ‘educated parents and trained them in adapted communication tailored to their child’s individual competencies’.

The study reported significantly greater improvements in the treated vs. untreated group of children with autism, on a range of outcome measures: total scores on the Autism Diagnostic Observation Schedule, expressive language, parent-child interaction, and the children’s initiation of communication. The authors concluded:

'this study suggests that a specific intervention that addresses bi-directional adult/child communication breakdown, joint attention, and is tailored to the specific needs of the cases can improve autistic symptoms across severity and age groups in terms of quality reciprocal communication and expressive language'.

Like RDI, this treatment approach provided specialized structured interventions that scaffold social interaction. The uniqueness of RDI lies in its sharper focus on links between social relatedness and the capacity to engage in flexible thinking and coping through the guided-participation relationship.

3. RDI is founded upon developmental principles that have been subject to programmatic research studies at the Developmental Psychopathology Research Unit at the Tavistock Clinic and ICH/UCL (e.g., Hobson, 2002).

In particular, RDI focuses on aspects of autism that are pivotal for the development and maintenance of almost all the distressing features of the syndrome, and in particular, the children’s limited interpersonal engagement with other people and their accompanying propensity to becoming ‘stuck’ in particular, one-track modes of thinking.

The focus of RDI is what happens between the affected child and his or her caregivers, with special attention to emotional contact and behavioural regulation. Thus RDI studies how a given child with autism has difficulties in engaging with another person emotionally; then it provides coaching for the carer to foster the child’s potential for such engagement, reducing the likelihood that moments of engagement (which are often fleeting) are lost. Perhaps most important, RDI allows the child to enjoy and build upon the engagement that is achieved. Such interpersonal engagement is hugely important not only for the child’s wellbeing and the parent’s ability to relate sensitively, but also for improving the child’s self-regulation, communication, and more flexible and appropriate thinking.

The intervention is concerned with fostering parenting, rather than attempting to modify children’s functioning over a protracted series of brief sessions. It is widely accepted that when appropriately designed, parent interventions have special promise for fostering development among children with autism.

In a series of recent (and ongoing) studies, J. A. Hobson and colleagues (Hobson et al., 2008; Hobson & Hobson, 2008; Hobson, 2009; Hobson et al., 2009; Hobson & Gutstein, 2010), have followed children/adolescents with autism and their families (participating in RDI programs) over time. On the basis of prospective study and retrospective chart review, preliminary results of the above studies (note: research is ongoing) suggest that this approach may yield significant changes in global clinical/psycho-social functioning as well as in improving qualities of parent-child interaction and social communication.

Finally, there arises the question of cost-effectiveness. This has not been subject to formal study. However, one of the great advantages of RDI is that it can be time-limited, yet its effects on parental functioning and through this, on affected children’s social relations and cognitive functioning, are sustained over much longer periods. Personally, we are strongly of the view that the substantial lifetime benefits of RDI more than justify its cost – but as yet, there is not quantitative evidence on the matter.

Hobson, R.P., & Hobson, J.A. (2008). Interpersonal engagement: A focus for understanding and intervention in autism. In symposium on The understanding and treatment of autism: A revolution in the making? Organized by R.P. Hobson, Annual Meeting of the Royal College of Psychiatrists, July.

Hobson, J. A. (2009). The guided participation relationship as a focus for change in children with autism and their parents. Presentation at the biennial meeting of the Society for Research in Child Development, Denver, CO USA, April.

Studies are underway with the Institute of Child Health at UCL and the Tavistock Clinic in London following cases in treatment prospectively. Reports on cases seen through the Connections Center but coded and analyzed independently by a separate research team blinded to treatment details have been presented in numerous conferences, and we have a collaborative paper with Dr Gutstein under review. The more sophisticated study, with a sample from an independent site is nearly complete and data analyses will be conducted over the summer.